R-5688 APPLICATION FOR CITY OF CUPERTwo PERMIT
u BER R- 56 8 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS '/�//1
7563 H O '(cLr/J`v J to cp, RESIDENTIAL,&—COMMERCIAL OTHER
OWNER'S ^ HAZARDOUS FIRE AREA
✓., •l_I I�Y_� „s Kc
,, YES ❑ If yes—I understand that a Claw A
NAME raj V V \ K of assembly is required.
;1�J IN - Initial I.C.B.O.N
ADDRESS ^7 S� (�( `ia vide' f:4 C (C�l EXISTING ROOF COVERING
PHONE 2 S "' j' () NUMBER OF EXISTING COVERINGS
CONT
NAME C�f CAr(1� � I/y TO BE REMOVED�TO BE RETAINED lnChL
� NAME yJ�.I/l r�� J JJI IJCY/('LSn
CITY ADDRESS ZIP �� TYPE OF ROOF COVERING
�( Q Q EX
ISTING
PHONE c2p 4 7 tk_-)Ps BUILT-UP ROOFLICENSE ❑
IR
NUMBER �Q C��J ASPHALT SHINGLES �pI(�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect.
2 WOOD SHINGLES ❑
License Class � Lic.Number
Q
Date Contractor OTHER(SPECIFY) ❑
OW from th Cor- CLA License PROPOSED
hereby affirm that am exempt from the Con adore License Lew for the following reason.
(Sac.construct,
It Business and Professions Code: Any city or county which requires a permit to
applicant
to file signed air statement
eny mentrthat structure,prior tolls Issuance,pursuant
Into ra quires the BUILT-UP ROOF ❑
applicant Mr such permit to lila a signed statement that he Is licensedSection
pursuant to the provisions
• of the ss and
License Lew)or that
h(commencing with therefrom
and]000)of Dlvislhe 3 at the
Busineexempas antl violation of Code)or that ha Is exempt antforam end the heels forhe the alleged ASPHALT SHINGLES
exemption.Anyviolationnot ion of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than floe hundred dollars(h wag): WOOD SHAKES
❑I,k, owner of the property,or to dedemployeeswith wages as their sole compensation,will s. ❑
the work,and the ontracte Is not Intended or offered for sale(Sea owner
of Business and Profen.
Ilona Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through ev own employees,or provided that ❑
such improvements are not Intended or offered for sale.ill however,the building pr o i Improvement
Is not ld bullwithin
or
prove for purpose of
Owner.bullderwlll have the burden of proving that he dltl OTHER(SPECIFY) ❑
not hullo or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sac.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR, INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner ode APPLICATION DATE VALUATI EMI
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peneity of perjury one of the following declaration:
s ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this J n��
��
permit is Issued. t$e15 IC
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of C�'r j'
the Labor Code,for the performance of the work for which this permit is Issued.My Worker's
Compensation Insurance carrier and Policy number are: UJ' Uu tt Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.D Z�
(This section need not be completed If the permit Is for one hundred dollars($100)or less.)
I certlly that in the performance of the work r which tele permit is Issued I shall not employ
any person In any manner so as to become I pt to the Warfare caminfin lon Laws of Cali- All roofs shall be inspected prior to an roofing ml being
fotnia^/ installed. If a roof is installed without first obtaining an
Dere •� Appllcant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after ma his Certificate of Exemption,you should become Applicant understands and om I with all non point
subject to the Workers'Compensation p Iona of the Labor Cotle,you must forthwith comply P y P
with such provisions or this permit shell deemed revoked. Source regulations.
I certify that l have read this appllcad n and state that the above Information is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,entl All of coverings to bejq;jj�j' better.
hereby authorize representatives of this city to enter upon the above-mentioned property far In-
spection purposes.
(We)agree to save,Indemnity and heap harmless the City of Cupertinoagalnat liabilities,
• of the granting of this perdgments,costa and mit,
which may In any way accrue against said Cly In consequanca S A URE OF APPLI ANT ATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP, DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
SUBJECT: REROOFIRNG POLICY FOR THE CITY OF CUPERTNO EUI DLtiG DEPART ,IE`-i
PRIOR TO ISSUANCE OF PERNU T AND NSpECTION PRASE.
omply with U.B.C. standards and manufacture-.s sec's
1. Prior to pe it issuance, you mus: ag r_ to c
on reroofing.
2. New roof coverings shall not be applied without first obtaining all in_�'ection and written aceroval
t from the hulloing inspr_:or. A final in_cec.ion and approval shall be obtained from the building
insocc:ar when the reroofing is completed.
3. All types of roof shall be inspected prior to any roof being installed.
4. In order to receive a final,you must camulete steps 1,2, and 3.
1,) Preinspection or tear off approval.
2.) In progress in erection approval.
3.) Final inspection approval.
a.) Operable smoke dere=:or verincauon
• b.) Spark arrestor installation
5. . If plywood is installed,a plywood trail inspection is required.
6. If any roof is applied without firs obtaining an inspection, you will be required to remove all new
material down to the sheathing and a building inspecill tor winre�_.all sheathing at that time.
NVE UNDERSTAND THE ABOVE POLICY ON REROOFING P—ND WT—1 COMPLY =H Tu
POLICY o
EO'tvMOWNERS NAME: �
7S� :� ko IICy. de-r v- \/ C
ADDRESS:`.
RERooFIN coiv>PANY NA. J a v�eS �� eOlY1S lJ� n �o v�
APPLICANT'S SIGNATURE:
CIT!OF CUPERTNO
BUILDING DEPAPMMENT
Reroof/wimvard